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MANAGEMENT OF DELAYED PERFORATION AFTER ESOPHAGEAL ENDOSCOPIC SUBMUCOSAL DISSECTION USING VAC-STENT

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Introduction

The vacuum-assisted closure stent (VAC-stent) is a novel approach for managing esophageal defects, combining endoscopic vacuum therapy (EVT) and metal stent support to promote effective tissue healing [1].
We present a case of esophageal perforation following circumferential Endoscopic Submucosal Dissection (ESD), successfully managed with a VAC-Stent (video 1).

Aims & Methods

We report a case of a 59-year-old man with a 40mm lesion involving 75% of the esophageal circumference (Paris 0-IIa + Is), arising in Barrett’s esophagus (Prague C4M5) and consistent with adenocarcinoma, who was referred to our unit. CT scans excluded metastatic disease, and after multidisciplinary consultation, ESD was planned.

Results

Circumferential ESD was performed using a triple-tunnel approach. After the resection, muscular tears were closed with through-the-scope (TTS) clips, and pre-emptive Endoscopic Vacuum Therapy (EVT) was applied to enhance granulation and healing.
Due to rising inflammatory markers and fever onset, an esophagogastroduodenoscopy (EGD) was performed on the 3rd Post-Operative Day (POD). The EGD revealed two <5mm perforations 4cm apart, and a VAC-stent was placed to bridge the defects. At the follow-up EGD on the 9th POD, a single defect remained, and a new VAC-Stent was placed. The patient showed progressive clinical improvement and successfully resumed a liquid diet. By the 15th POD, the perforations had healed.
The patient was discharged in good clinical condition on the 18th POD.
At the EGD on the 30th POD, homogeneous healing tissue was observed, with no stricture detected at the resection site.
Histological analysis of the ESD specimen revealed moderately differentiated adenocarcinoma with submucosal invasion: pT1b (sm1) pNX G2, with R0 resection achieved and no high-risk pathological features. An oncological and endoscopic follow-up was planned.

Conclusion

Our case demonstrates that the VAC-Stent is a safe and effective method for treating perforations following esophageal ESD. In cases of circumferential ESD, VAC-stent use may also help prevent strictures.

References

[1]. Dell’Anna G, Fanti L, Fanizza J, et al. VAC-Stent in the Treatment of Post-Esophagectomy Anastomotic Leaks: A New “Kid on the Block” Who Marries the Best of Old Techniques—A Review. Journal of Clinical Medicine 2024; 13: 3805. doi:10.3390/jcm13133805

MANAGEMENT OF DELAYED PERFORATION AFTER ESOPHAGEAL ENDOSCOPIC SUBMUCOSAL DISSECTION USING VAC-STENT

Francesco Vito Mandarino 1, Gabriele Altieri 1, Giuseppe Dell'Anna 2, Alberto Barchi 1, Ernesto Fasulo 1, Francesco Azzolini 1, Silvio Danese 1, Edi Viale 1

1 IRCCS San Raffaele Institute, Milan, Italy|||Vita-Salute San Raffaele University, Milan, Italy

2 IRCCS San Raffaele Institute, Milan, Italy|||IRCCS Policlinico san Donato, Milan, Italy

Event

UEG Week Berlin 2025

Topics

Digestive Oncology Endoscopy Oesophagus

Submission format

Video Case

Session

Video Case Session: Third space endoscopy

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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Robotic living donor hepatectomy: A novel tool to expand the donor pool

Moritz Schmelzle 1

1 Hannover Medical School, Hannover, Germany

Event

UEG Week Berlin 2025

Topics

Hepatobiliary Surgery

Session

New developments in liver transplantation

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

UEG Presentation

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ESOPHAGEAL FUNCTION TESTING IDENTIFIES ASYMPTOMATIC BARRETT’S ESOPHAGUS PATIENTS WITH PATHOLOGICAL ACID EXPOSURE AT RISK FOR NEOPLASIA: A MULTICENTER STUDY

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Introduction

Pathological esophageal acid exposure may persist in patients with Barrett’s esophagus (BE) despite standard proton pump inhibitor (PPI) therapy and symptom control, although current guidelines recommend at least standard-dose PPI for all patients with BE.¹

Aims & Methods

Aim was to evaluate the role of esophageal function testing in assessing acid exposure in BE patients on PPI therapy and in predicting neoplastic progression. We conducted a multicenter retrospective study including asymptomatic BE patients (defined by GerdQ total score <8 and a score of 0 on the first GerdQ item) who underwent high-resolution manometry and 24-hour pH impedance monitoring while on various PPI regimens. Maximal PPI therapy included esomeprazole 40 mg, pantoprazole 40 mg, rabeprazole 20 mg, or lansoprazole 30 mg, all administered twice daily. All other regimens were considered standard dosing. Index upper endoscopy with biopsies was performed under the same therapeutic regimen. Histologically, presence and degree of neoplasia (all confirmed by a second pathologist) was recorded. Acid exposure time (AET) <4% was defined as adequate acid control; AET >6% as pathological reflux. Predictors of pathological reflux and neoplasia were assessed using logistic regression analysis.

Results

A total of 135 patients (2016-2025) were included (mean age 58 ± 15 years; 73% male). Median BE length was C1 (range 0–3 cm) and M2 (range 1–5 cm), with 41% (n=56) classified as having long-segment BE. Sixty-seven patients (50%) were on standard-dose PPI. Pathological reflux was identified in 37 patients (27%), of whom 25 (67%) were on standard-dose therapy. Fourteen patients (10%) had borderline AET values (4–6%). Among the 84 patients (62%) with adequate acid control, 33 (39%) were taking standard-dose PPI. On multivariable analysis, standard-dose PPI (OR 3.04; 95% CI 1.34–6.89; p=0.008) and type III esophagogastric junction morphology (OR 2.52; 95% CI 1.01–5.01; p=0.047), consistent with manometric hiatal hernia, were independently associated with pathological reflux. Non-dysplastic BE was found in 112 patients, while 13 (10%) had neoplasia at index endoscopy (8 low-grade dysplasia, 3 high-grade dysplasia, 2 intramucosal adenocarcinoma). Pathological reflux was the only independent predictor of neoplasia (OR 10.41; 95% CI 2.65–41.26; p<0.001).

Table 1. Logistic regression analysis for factors associated with neoplasia on index endoscopy.

	Univariable analysis		Multivariable analysis
	OR (95% CI)	p-value	OR (95% CI)	p-value
Age, years	1.01 (0.96-1.05)	0.695	-	-
BMI, kg/m²	0.95 (0.83-1-10)	0.957	-	-
Male gender	0.71 (0.19-2.54)	0.783	-	-
PPI standard dose vs maximal	0.85 (0.27-2.69)	0.792	-	-
Long-segment BE vs short	1.70 (0.53-5.52)	0.371	-	-
Ineffective/absent contractility vs normal	0.96 (0.30-3.03)	0.939	-	-
EGJ type III morphology vs I/II	3.98 (1.16-13.71)	0.028	3.18 (0.86-11.78)	0.082
AET >6% vs <6%	11.72 (3.01-45.65)	0.001	10.41 (2.65-41.26)	<0.001

Conclusion

Nearly one-third of asymptomatic BE patients exhibit pathological reflux on pH-monitoring despite PPI treatment, predominantly among those on standard-dose and with manometric hiatal hernia. Nonetheless, adequate acid control is achieved in over one-third of patients on standard PPI therapy. Pathological reflux is associated with a 10-fold increased risk of neoplasia.

References

1. Shaheen NJ, Falk GW, Iyer PG, et al. Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline. Am J Gastroenterol. 2022;117(4):559-587.